Download Anxiety in individuals with and without cognitive impairments

Anxiety in individuals with and without cognitive impairments Ladislav Volicer, MD, PhD
School of Aging Studies, University of South
Florida, Tampa, FL and
3rd Medical Faculty, Charles University,
Prague, Czech Republic
ANXIETY
• An unpleasant state of inner turmoil, often accompanied by nervous behavior, such as pacing back and forth, somatic complaints and rumination
• Feeling unrealistic fear, worry, and uneasiness, usually generalized and unfocused
• Often accompanied by restlessness, fatigue, problems in concentration, and muscular tension
Types of Anxiety
• Generalized Anxiety Disorder ‐ excessive, uncontrollable and often irrational worry about everyday things that is disproportionate to the actual source of worry
• Social Phobias
• Test and performance anxiety
PHOBIAS
Ablutophobia – fear of bathing, washing, or cleaning Achluophobia – fear of darkness Acrophobia – fear of heights Agoraphobia– fear of places or events where escape is impossible or when help is unavailable. Agrizoophobia – fear of wild animals Agyrophobia – fear of crossing the road Aichmophobia – fear of sharp or pointed objects Ailurophobia – fear of cats Algophobia – fear of pain Amychophobia – fear of being scratched
Anthophobia – fear of flowers
Anthropophobia – fear of people
TREATMENT OF PRIMARY ANXIETY
• Psychotherapy: Cognitive Behavioral Therapy (CBT), Hypnotherapy
• Pharmacological:
– Beta blockers – somatic symptoms
– Anxiolytics – benzodiazepines, hydroxyzine, pregabalin
CONDITIONS THAT MAY CAUSE ANXIETY
• Medical conditions: chronic obstructive pulmonary disease (COPD), heart failure, or heart arrythmia
• Other psychiatric conditions: depression, schizophrenia, obsessive‐compulsive disorder, Posttraumatic Stress Disorder, Substance Induced Anxiety Disorder
• Dementia
• Caregiving
• End of life
Features of Schizophrenia
Positive symptoms
Delusions
Hallucinations
Functional Impairments
Work/school
Interpersonal
relationships
Self-care
Cognitive deficits
Attention
Memory
Verbal fluency
Executive function
(eg, abstraction)
Disorganization
Speech
Behavior
Negative symptoms
Anhedonia
Affective flattening
Avolition
Social withdrawal (most
predictive of poor outcome)
Alogia
Mood symptoms
Depression/Anxiety
Aggression/Hostility
Suicidality
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Assessing the Degree of Suicidal Risk
[Behavior or Symptom] [Intensity of Risk]
Low
Moderate
High
Anxiety
Mild
Moderate
High, or panic state
Depression
Mild
Moderate
Severe
Isolation-withdrawal
Some feelings of
helplessness,
hopelessness, and
withdrawal
Fairly good in most Moderately good in
activities
some activities
Hopeless, helpless
withdrawn & selfdeprecating
Several
Few or none
Daily functioning
Resources
Vague feelings of
depression, no
withdrawal
Some
Not good in any
activities
(Hatton D, Valente S. Rink A: Suicide Assessment and Intervention, p.56. New York, Appleton-Century-Crofts. 1977)
PROCEDURE:
1.Review the resident’s level of suicidal risk using the table “Assessing the Degree of Suicidal Risk.”
•If the risk is moderate or high, contact the family and physician.
•If social services is interacting with the health care professionals, include this information in the plan of care and reference in the
progress notes.
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DEPRESSION AND ANXIETY
Anxiety Disorder
Pure
Comorbid Comorbid
Disorder Depression Anxiety
--------------------------------------------------------------------Gener.anx.dis.
70%
30%
Phobia
75%
25%
Panic
50%
50%
Obses.comp.dis. 56%
44%
Major depression 53%
47%
--------------------------------------------------------------------Beekman et al, Am.J.Psychiatry 157:89-95, 2000
ANXIETY IN DEPRESSION
• Treat depression not anxiety
• Anxiolytics
– Do not resolve depression
– Do not reduce suicide risk
– Increase risk of falls and hip fracture
– Decrease CNS functioning (Granek et
al, J.Am.Geriat.Soc. 35:503-511, 1987)
Relationship between the MDS diagnosis of
depression and the treatment with antipsychotics and
antianxiety medications
MDS diagnosis
Total
Chi2
p
No depression
Mild depression
Severe depression
Antipsychotics (24.6% dg psychosis)
18.3%
(191/850)
32.9%
(149/304)
44.0%
(155/197)
26.8% 99.74 <.001
(495/1351)
Antianxiety (17% dg anxiety)
10.6% (110/931)
15.5%
(70/383)
24.4% (86/266)
14.4%
41.53 <.001
(266/1580)
Percentages refer to proportion of treated residents in the cell.
Numbers refer to the ratio of treated over untreated residents.
LOW DETECTION
• Depression (1997-1998 surveys)
– Older patients (56% less likely)
– African-Americans (37% less likely)
– Medicaid (35% less likely)
• Family physicians 65% more likely to
record a diagnosis than internists
• Anxiety detection rate 10%
Harman et al, J.Gen.Intern.Med. 17:165-172, 2002
CONSEQUENCES OF COMORBID
ANXIETY
•
•
•
•
Greater severity of depression
Greater likelihood of suicidal ideation
Lower social function
Greater severity of somatic symptoms
Lenze et al, Am.J.Psychiatry 157:722-728, 2000
COMBINATION OF DEPRESSION
AND ANXIETY INCREASES
• Dysfunction, suffering, diminished quality
of life
• Physical symptoms
• Disability
• Utilization of healthcare resources
• Medical mortality and suicide
After Mulsant BH
PSYCHOTHERAPY FOR DEPRESSION
• Psychodynamic Therapy
• Interpersonal Therapy
• Cognitive Behavioral Therapy – Rational emotive behavior therapy
– Dialectical behavior therapy
MUSIC THERAPY
• Weekly music and activity program decreased behavioral and depressive symptoms (Han et al, Dement Geriatr Cogn Disord 30, 540, 2010)
• Biweekly music therapy improved symptoms of depression (Raglio et al, Curr Aging Sci 3, 242, 2010)
• Weekly individual music therapy sessions decreased anxiety and depression (Guetin et al, Dement Geriatr Cogn Disord 28, 36, 2009)
• RTC trial of music therapy found decreased number of depressive symptoms and improved self‐esteem (Cooke et al, J Health Psychol 15, 765, 2010)
ANTIDEPRESSANT
SELECTION
• Tricyclic antidepressant obsolete because of
side effects (anticholinergic, cardiovascular)
except when cost is a concern
• Selective serotonin reuptake inhibitors are
first choice
– Citalopram (Celexa)
– Sertraline (Zoloft)
• Venlafaxine (Effexor) first alternative
RESIDUAL SYMPTOMS IN
DEPRESSION
• Residual insomnia
– Trazodone
– Zolpidem (Ambien)
– Zaleplon (Sonata)
• Residual anxiety
– Increase the dosage of the antidepressant
2001 Geriatric Depression Guidelines
DEMENTIA
Memory Social withdrawal DEPRESSION
impairment Impaired concentration Depressed mood
Aphasia Sleep disruption Irritable mood
Apraxia Loss of interest Loss of energy
Agnosia Feeling of
Executive hopelessness
impairment Excessive worry Feeling of
Agitation
helplessness
Suicidal thoughts
Impaired appetite
Physiological arousal
Phobias
Panic attacks
ANXIETY DISORDER
ANXIETY IN MCI
• 161 patients, anxiety in 52%
• Associated with earlier conversion to AD (Gallagher et al, Int J Geriatr Psychiatry. 2011 Feb;26(2):166‐72)
LOW HIGH
Wilson et al, Am J Geriatr Psychiatry. 2011 Apr;19(4):327
ANXIETY IN DEMENTIA
• At first dg (mild dementia)
– 19.5% had clinically significant anxiety – 22.5% had subclinical anxiety. Half of the patients reported experiencing anxiety from time to time.
– More in Lewy‐body dementia than in Alzheimer's disease (Hynninen et al, Int Psychogeriatr. 2012, 24(11):1771)
• Related to agitation (not symptoms of autonomic sensitivity) (Twelftree et al, Aging Ment Health. 2006 Jul;10(4):362)
ANXIETY IN ASSISTED LIVING
• Similar prevalence in residents with and without dementia: 45% at least mild anxiety by examination, 22% by proxy (Smith et al, Res Gerontol Nurs. 2008 Apr;1(2):97)
• Anxiety in 11 ‐18% of residents with dementia, related to staff skill (Neville & Teri, Int J Ment Health Nurs 2011 20(3):195)
NON‐PHARMACOLOGICAL TREATMENT
• Music therapy – percussion instruments with familiar music, 30 min/day, 2/week, for 6 weeks (Sung et al, Int J Geriatr Psychiatry 2012;27(6):621‐7)
• Preferred music listening – 30 min/day, 2/week, for 6 weeks (Sung et al, J Clin Nurs. 2010 Apr;19(7‐8):1056)
• RTC – weekly receptive music therapy (Guetin et al, Dement Geriatr Cogn Disord 2009;28:36)
ACTIVITY PROGRAMS
I
N
D
E
P
E
N
D
E
N
C
E
MILD
MODERATE
MEMORY
ENHANCEMENT
PROGRAM
SEVERE TERMINAL
NAMASTE CARE
THE CLUB
TIME
NAMASTE CARE
• Presence of others – group room, carer
always present (7 days/week, 5hrs/day)
• Comfortable environment – reclining chairs,
bird sounds, relaxing music, lavender scent
• Individualized care – hand and foot
massage, ADL as meaningful activities
• Easy to implement, no additional staffing
J. Simard: The End-of-Life Namaste Care Program for
People with Dementia, Health Professions Press 2007
Psychoactive Medications before and after Namaste Enrollment
Medication
Antipsychotics
Days
administered
2.57
2.72
Number of
residents
32
34
Antianxiety
0.80
0.49*
11
6
Antidepressants
4.37
4.14
54
52
Hypnotics
0.05
0.01
1
1
* p = .035
NEUROPSYCHIATRIC
INVENTORY (NPI)
•
•
•
•
•
•
Delusions
Apathy
Hallucinations
Disinhibition
Agitation/aggression
Depression
• Aberrant motor
behavior
• Anxiety
• Night-time behavior
• Euphoria
• Appetite and eating
changes
Cummings et al, Neurology 44:2308-2314, 1994
Effect of Galantamine on
Behavioral Symptoms in AD
Dose increments
Mean (± SE) change from
baseline in NPI
–3
–2
Improvement
–1
*
0
1
2
†
3
Placebo
Galantamine 16 mg/d
Galantamine 24 mg/d
4
5
6
0
3
1
Months
* p < 0.05 vs placebo (galantamine 16 and 24 mg).
† p < 0.05 vs baseline.
5
Deterioration
Reprinted with permission
from Tariot PN et al.
Neurology. 2000;54:22692276.
Effect of galantamine on Behavioral Symptoms in AD
NPI Individual Items
Aberrant Motor Behavior
Agitation/Aggression
Anxiety
Apathy
Delusions
Depression/Dysphoria
Disinhibition
Elation/Euphoria
Hallucinations
Irritability
NPI Distress
Total NPI
Highlighted = Clinical significance (p < 0.05) over 5 months for
GALANTAMINE 24 mg/day vs placebo.
Tariot PN et al. Neurology. 2000;54:2269-2276.
Galantamine effect in vascular dementia
Mean (± SE) change in NPI score from baseline
–3
Improvement
–2
*
–1
0
1
2
3
4
REMINYL 12 mg bid (n = 106)
Placebo (n = 106)
5
6
Baseline M1
M3
M5
Deterioration
* p < 0.05 vs placebo.
Baseline Neuropsychiatric Inventory (NPI) score: 15 (REMINYL 12 mg
Wilkinson DG et al. IJCP. 2002;56:509-514.
bid)/13 (placebo).
Change in NPI Items in vascular dementia
Aberrant motor behavior
Agitation/aggression
Anxiety*
Apathy/indifference*
Delusions*
Depression/dysphoria
Disinhibition
Elation/euphoria
Hallucinations
Irritability/lability
* p < 0.05 vs. placebo.
Adapted from Erkinjuntti T et al. Lancet. 2002;359(9314):1283-1290. Data on file, Janssen Pharmaceutica Products, L.P.
*
*p<0.05 vs baseline; ***p<0.001 vs
baseline
*
-3
*
-2.5
*
-2
*
***
Improvement
-3.5
*
*
-1.5
-1
-0.5
Appetite/eating
Nighttime beh.
Euphoria
Disinhibition
Delusions
Depression
Hallucinations
Study B452; Observed case analysis
Apathy
Aberr. motor
behavior
Anxiety
Irritability
0
Agitation
Mean Change from Baseline
BEHAVIORAL EFFECTS OF
RIVASTIGMINE
Cummings JL, et al. Behavioral benefits in Alzheimer's disease patients residing in a nursing home following
52 weeks of treatment with rivastigmine. Presented at the APA 2000 Annual Meeting, May 13-18, 2000, Chicago
Memantine in Moderate to Severe AD
Mean Change From Baseline
in NPI Score
‐0.6
‐0.4
Memantine
Placebo
*P=.0386
‐0.2
*P=.0083
Improvement
Worsening
0.0
0.2
0.4
0.6
0.8
1.0
Delusions Hallucinations Agitation/ Depression/
Aggression Dysphoria
*LOCF analysis at Week 28
Source: Data on file. Forest Laboratories, Inc.
Anxiety
Elation/
Euphoria
PSYCHIATRIC CONSEQUENCES
OF CAREGIVING
• ANXIETY - in 21 - 76 % of caregivers, related
to hours of care, physical and psychological
illness scores, low education, lack of time for
leisure activities (Vellone et al, 2002, Sansoni
et all, 2004)
• CBT improved anxiety and coping strategies
in caregivers, and neuropsychiatric symptoms
and quality of life in care recipients (Fialho et
al, Arq Neuropsiquiatr.. 2012, 70(10):786‐92)
CAREGIVING BURDEN
PRIMARY STRESSORS
Care recipient disability
Psychiatric symptoms
Care decisions
SECONDARY STRESSORS
Family conflict
Work difficulties
Appraisal of demands and adaptive capacity
Perceived stress
Emotional/behavioral response
MORBIDITY/MORTALITY
Adapted from Schulz and Martire, Am J Geriatr Psychiatry 12:204, 2004
PSYCHIATRIC PROBLEMS AT THE END OF LIFE
•
•
•
•
•
Depression
Anxiety
Insomnia
Delirium
Fatigue
ANXIETY
• May be a normal response to the situation –
fears, uncertainty, reaction to physical condition, social or spiritual needs
• Usually with 1 or more of the following signs –
agitation, restless, sweating, tachycardia, hyperventilation, insomnia, excessive worry, tension
• About 5% are affected by agoraphobia
ANXIETY AT END OF LIFE
• Much anxiety near the end of life may stem from not talking.
• People think that the dying person doesn't know she's dying and don't want to tell her, and the dying person absolutely knows that she's dying but doesn't want to burden her loved ones. So nobody's on the same page. (Marsha Gallagher, LCSW, a social worker with Capital Caring)
NEED FOR PALLIATIVE CARE IN DEMENTIA
• Symptoms during last 3 months – Physical: pain 86%, problems with personal cleanliness 81%, dyspnea 75%, incontinence 59%, fatigue 52%
– Emotional: depressed mood 44%, anxiety 31%, loneliness 21%
• More treatment needed for emotional symptoms, personal cleanliness, pain
• Good death reported in 58%
Reynolds et al, J Palliat Med 5;895,2002
CANCER‐RELATED FATIGUE
•
•
•
•
•
•
•
•
•
•
Direct effect from cancer and/or treatments
Sedating medications
Deconditioning
Depression/anxiety
Hypoxemia or anemia
Systemic infection of organ insufficiency
Electrolyte abnormalities
Nutritional imbalance/impairment
Sleep disturbance
Uncontrolled pain
Copyright © 2010 Center for Hospice, Palliative Care , & End‐Of‐Life Studies
41
ANXIETY DISORDER IN ADVANCED CANCER
• Diagnosed in 7.6% of patients
• More likely in women, younger patients, with worse physical performance status
• Had less trust in their physicians, felt less comfortable asking questions about their health, and felt less likely to understand the clinical information that their physicians presented
• Were more likely to believe that their physicians would offer them futile therapies and would not adequately control their symptoms.
Spencer et al, Cancer. 2010 Apr 1;116(7):1810‐9
SYMPTOMS BEFORE DEATH IN PALLIATIVE CANCER PATIENTS
Symptom
One-month mean One-week mean
(SD)
(SD)
Appetite
46.8 (29.9)
60.3 (32.1)
Tiredness
43.2 (20.0)
58.5 (25.0)
Depression
32.9 (22.7)
38.5 (29.1)
Well-being
42.4 (23.5)
49.0 (23.4)
Pain
37.5 (22.7)
44.0 (26.9)
Anxiety
33.4 (24.0)
38.1 (28.5)
Nausea
18.4 (16.0)
25.7 (24.9)
Shortness of Breath
24.0 (21.1)
31.7 (27.2)
Drowsiness
39.8 (22.5)
55.6 (27.7)
Symptoms scored 0 = best possible to 100 = worst possible
Olson et al, BMC Medical Research Methodology, 8, 36, 2008
Copyright © 2010 Center for Hospice, Palliative Care , & End‐Of‐Life Studies
43
DEATH ANXIETY IN CAREGIVERS
• Younger nurses have more anxiety and have negative attitude towards end‐of‐life patient care
• Worksite death education program is needed to reduce death anxiety (Peters et al, Open Nurs J. 2013;7:14‐21)